<h4>Request a Call-back </h4>

    <form action="" method="post">

        <p>Your Name </p>

        <p>
            <input id="title" class="inputbox" style="width: 170px;" name="callback_name" value="<?=set_value('callback_name'); ?>" type="text" />
        </p>

        <p>Your Telephone Number </p>

        <p>
            <input id="forename" class="inputbox" style="width: 170px;" name="callback_telephone" value="<?=set_value('callback_telephone'); ?>" type="text" />
        </p>           

        <?
        if($this->input->post("callback_submit") !== FALSE){
            echo validation_errors(); 
        }
        ?>

        <p>
          <input onmouseover="this.src='<?=base_url()?>assets/website/images/buttons<?=INSTANCE_FILE_SUFFIX ?>/submitbutton_f2.gif'" onmouseout="this.src='<?=base_url()?>assets/website/images/buttons<?=INSTANCE_FILE_SUFFIX ?>/submitbutton.gif'" alt="Submit" name="callback_submit" value="Submit" name="image" src="<?=base_url()?>assets/website/images/buttons<?=INSTANCE_FILE_SUFFIX ?>/submitbutton.gif" type="image" />
          <input type="hidden" name="token" id="token" value="<?=$token?>" />
        </p>

    </form>

